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ICD-10 IS COMING OCTOBER 1, 2014 WHAT IS THE IMPACT ON THERAPY PRACTICES? CHET DESHMUKH, MBA, OTR/L, CPC, CHDA
ICD-10 IS COMING OCTOBER 1, 2014
WHAT IS THE IMPACT ON THERAPY PRACTICES?
CHET DESHMUKH, MBA, OTR/L, CPC, CHDA
Overview
Understanding the language of clinical diagnosis
What is ICD ?
About ICD-9 CM
Good Clinical documentation
Regulatory Impact
Clinical documentation changes
Introduction to ICD-10 CM
Examples
International Classification of Diseases
What is the International Classification of Diseases?
How did ICD come about?
Who is responsible for updating ICD?
WORLD HEALTH ORGANIZATION (WHO)
Good documentation means …
Accurate and timely charting
Key components of medical record s
Evaluation and Re-evaluation
Plan of Care
Treatment and Periodic Assessment
Status updates
Objective and measurable goals
Progress and desired Clinical Outcomes
Beginning of ICD Classification
François Bossier de Lacroix (1706-1777)
William Farr (1807-1883) - first medical statistician - classifications and international uniformity of preventable diseases
Jacques Bertillon (1851-1922) – List of Cause of Death
ICD – Current Version
We are in ICD- Ninth Version today
There are approx. 16,500 diagnosis codes
ICD-9 is set-up as an index
ICD-9 has 3, 4, 5 digit codes for each disease
Regulatory Impact
Coverage of therapy services
Payment for therapy services
Documentation requirements
Collection of accurate data
Submission of accurate data through claims
Reporting of quality indicators
Outcomes Measurement
Coverage of Therapy Services
ACTIVE PARTICIPATION of the clinician in treatment means that the clinician personally furnishes in its entirety at least 1 billable service on at least 1 day of treatment.
Assessment of Status
ASSESSMENT is separate from evaluation, and is included in services or procedures, (it is not separately payable).
The term assessment as used in Medicare manuals related to therapy services is distinguished from language in Current Procedural Terminology (CPT) codes that specify assessment, e.g., 97755, Assistive Technology Assessment, which may be payable).
Assessment is not a Re-evaluation
Assessments shall be provided only by clinicians, because assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s).
Assessment determines, e.g., changes in the patient's status since the last visit/treatment day and whether the planned procedure or service should be modified.
Plan of Care and Certification
CERTIFICATION is the physician’s/non-physician practitioner’s (NPP) approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.
Note: State rules may vary – check Scope of Practice.
Complications and Co-morbidities
COMPLEXITIES are complicating factors that may influence treatment, e.g., they may influence the type, frequency, intensity and/or duration of treatment. Complexities may be represented by diagnoses (ICD-9 codes), by patient factors such as age, severity, acuity, multiple conditions, and motivation, or by the patient’s social circumstances such as the support of a significant other or the availability of transportation to therapy.
Initial Evaluation
EVALUATION is a separately payable comprehensive service provided by a clinician, as defined above, that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted e.g., for a new diagnosis or when a condition is treated in a new setting.
Medical vs. Treatment Diagnosis
A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated. The diagnosis should be specific and as relevant to the problem to be treated as possible.
In many cases, both a medical diagnosis (obtained from a physician/NPP) and an impairment based treatment diagnosis related to treatment are relevant.
The treatment diagnosis may or may not be identified by the therapist, depending on their scope of practice. Where a diagnosis is not allowed, use a condition description similar to the appropriate ICD-9 code.
For example the medical diagnosis made by the physician is CVA; however, the treatment diagnosis or condition description for PT may be abnormality of gait, for OT, it may be hemiparesis, and for SLP, it may be dysphagia.
For PT and OT, be sure to include the body part evaluated. Include all conditions and complexities that may impact the treatment. A description might include, for example, the premorbid function, date of onset, and current function;
Re-evaluation
RE-EVALUATION provides additional objective information not included in other documentation. Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, or decline, or change in the patient's condition or functional status that was not anticipated in the plan of care.
Establishing a Plan of Care
The plan, (also known as a plan of care or plan of treatment) must be established before treatment is begun. The plan is established when it is developed (e.g., written or dictated).
The signature and professional identity (e.g., MD, OTR/L) of the person who established the plan, and the date it was established must be recorded with the plan.
Establishing the plan, is not the same as certifying the plan.
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Understanding ICD-10 CM
Countries who have adopted ICD-10
Canada
• Began adopting in 2001
• Over 5-year
implementation
• ICD-10-CA for morbidity
• Coding is used for
statistical purposes
rather than for billing
Australia
• Adopted in 1998
• Implementation took 2 years
• 2 years from decision to change to actual implementation was insufficient lead time to build the classification and educate users
Germany
• Adopted in 1998
• ICD-10-AM for morbidity
• Implementation took 3 years
France
• Adopted in 1996
United Kingdom
• Adopted in 1995
South Africa
• Adopted in 1996
Brazil
• Adopted in 1998
Russia
• Adopted in 1999
China
• Adopted in 2002
Countries who have adopted ICD-10Countries who have adopted ICD-10
Canada
• Began adopting in 2001
• Over 5-year
implementation
• ICD-10-CA for morbidity
• Coding is used for
statistical purposes
rather than for billing
Australia
• Adopted in 1998
• Implementation took 2 years
• 2 years from decision to change to actual implementation was insufficient lead time to build the classification and educate users
Germany
• Adopted in 1998
• ICD-10-AM for morbidity
• Implementation took 3 years
France
• Adopted in 1996
United Kingdom
• Adopted in 1995
South Africa
• Adopted in 1996
Brazil
• Adopted in 1998
Russia
• Adopted in 1999
China
• Adopted in 2002
SOURCE: http://www.who.int/classifications/icd/en/
ICD-10 Around the World
The United States is the only country in the industrialized world still using older ICD-9
codes for administration and health care delivery
From 18,000 codes to over 140,000 codes
ICD-10 Changes
Change to procedure codes is for inpatient only. Outpatient CPT codes are not impacted by ICD-10.
14,000
68,000
ICD-9-CM
ICD-10-CM
Diagnosis Codes
4,000
72,000
ICD-9-CM
ICD-10-CM
Procedure Codes
ICD-10-PCS
The Basics of the ICD-10 Change
X X X X X
.
ICD-9 ICD-10
X X X X X X X
Category Category Etiology, anatomic
site, manifestation
Etiology, anatomic
site, manifestation
. . Extension
An Example of Structural Change
Type 1 diabetes mellitus with diabetic neuropathy,
unspecified
E 1 0 4 0 .
Type 1 diabetes mellitus with diabetic mononeuropathy
E 1 0 4 1 .
Type 1 diabetes mellitus with diabetic amyotrophy
E 1 0 4 4 .
Type 1 diabetes mellitus with other diabetic neurological
complication
E 1 0 4 9 .
Diabetes mellitus with neurological
manifestations type I not stated as
uncontrolled
2 5 0 6 . 1
An Example of One ICD-9 code being
Represented by Multiple ICD-10 Codes
One ICD-9
code is
represented
by multiple
ICD-10 codes
Mapping ICD-9 and ICD-10 codes will be a complex task
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Guidelines under ICD-10 CM
Clinical Documentation Changes under ICD-10
Combination codes for conditions and manifestations e.g. Type I Diabetes Mellitus with Diabetic Nephropathy
Laterality – Right vs. Left; Dominant vs. Non-dominant
Episode of Care – Initial vs. Subsequent
Change in timeframes for certain diagnosis i.e. Myocardial Infarction
Important Note – Guidelines
ICD-10 CM does not provide a separate diagnosis code for PT/OT/ST.
Do not assign “aftercare codes” for aftercare post injuries. Use guidelines for selection of encounter type i.e. Initial vs. Subsequent Encounter
Do not assign a status code with a diagnosis code if the diagnosis code is specific and includes patient status e.g. Z94.1 - Heart Transplant Status and T86.2 – Complications of Heart Transplant.
Guidelines continued …
Documenting treatment of ongoing chronic conditions i.e. Diabetes Mellitus and the use of insulin.
If your patient is using insulin (independently or being administered) the medical record must document the same. This is even more important if you are treating a patient s/p surgery or for wound care as this demonstrates existing conditions that may delay the progress or justify additional visits due to medical necessity.
Guidelines continued …
Sequelae of Cerebrovascular Disease (Category I69).
“Late effects” include neurological deficits that persist after initial onset of conditions i.e. “loss of movement”, “loss of balance and equilibrium” etc ..
Document clearly if the neurologic deficits caused by the cerebrovascular disease were present from the onset or were identified at anytime after the onset of the primary neurological condition.
Guidelines continued …
Use the correct ‘Extension’ character for complications and conditions that arise as a direct result of an injury i.e. Scar formation after a burn.
Document the injury and sequela. The primary reason for the therapy treatment is not the burn it is the scar.
Therapy documentation must indicate that the reason for the treatment is “Scar due to Burn (and describe the burn and the scar).
More guidelines …
External cause status – when evaluating your patient and documenting the history make note of the external cause status of the injury i.e. indicate whether the event occurred during military activity, whether a non-military person was at work, whether and individual including a student or volunteer was involved in a non-work activity at the time of the event.
Guidelines continued …
A fracture not clearly identified as “open” or “closed” will be coded to “closed”.
How will this impact your revenue?
Describe the type of injury and condition at the time of occurrence as this will demonstrate the need for level of care e.g. 65 year old male was referred/ admitted for OT services following hospitalization for Type 1 Open Traumatic Fracture of the left radius and ulna.
More documentation clarity for ICD-10…
Orthopedic cases will need additional documentation clarity from physicians …
Type and Classification of Fracture
Salter-Harris
Gustilo Classification for Open Fractures e.g.
Type I – Low energy, wound less than 1 cm
Type II – Wound greater than 1 cm with moderate soft tissue damage
Etc.
Examples
ICD-9 Code Description
ICD-10 CM Codes
724.2 LUMBAGO M54.5 LOW BACK PAIN
723.1 CERVICALGIA M54.2 CERVICALGIA
719.46 JOINT PAIN-LOWER LEG M25.561 PAIN IN RIGHT KNEE
M25.562 PAIN IN LEFT KNEE
M25.569 PAIN IN UNSPECIFIED KNEE
719.41 JOINT PAIN-SHOULDER REGION M25.511 PAIN IN RIGHT SHOULDER
M25.512 PAIN IN LEFT KNEE
M25.519 PAIN IN UNSPECIFIED KNEE
ICD-9 Code Description ICD-10 CM Codes
813.42 OTHER CLOSED FX DISTAL END OF RADIUS NEC S52.501A UNSPECIFIED FRACTURE OF THE LOWER END OF THE RIGHT RADIUS
S52.502A UNSPECIFIED FRACTURE OF THE LOWER END OF THE LEFT RADIUS
S52.509A UNSPECIFIED FRACTURE OF THE LOWER END OF THE UNSPECIFIED RADIUS
S52.511A DISPLACED FRACTURE OF RIGHT RADIAL STYLOID PROCESS
S52.512A DISPLACED FRACTURE OF LEFT RADIAL STYLOID PROCESS
S52.513A DISPLACED FRACTURE OF UNSPECIFIED RADIAL STYLOID PROCESS
S52.514A NONDISPLACED FRACTURE OF RIGHT RADIAL STYLOID PROCESS
S52.515A NONDISPLACED FRACTURE OF LEFT RADIAL STYLOID PROCESS
S52.516A NONDISPLACED FRACTURE OF UNSPECIFIED RADIAL STYLOID PROCESS
S52.521A TORUS FRACTURE OF LOWER END OF RIGHT RADIUS
S52.522A TORUS FRACTURE OF LOWER END OF LEFT RADIUS
S52.529A TORUS FRACTURE OF LOWER END OF UNSPECIFIED RADIUS
S52.531A COLLES' FRACTURE OF RIGHT RADIUS
S52.531A COLLES' FRACTURE OF LEFT RADIUS
S52.531A COLLES' FRACTURE OF UNSPECIFIED RADIUS
S52.541A SMITH'S FRACTURE OF RIGHT RADIUS
S52.542A SMITH'S FRACTURE OF LEFT RADIUS
S52.549A SMITH'S FRACTURE OF UNSPECIFIED RADIUS
S52.551A OTHER EXTRA-ARTICULAR FRACTURE OF LOWER END OF RIGHT RADIUS
S52.552A OTHER EXTRA-ARTICULAR FRACTURE OF LOWER END OF LEFT RADIUS
S52.559A OTHER EXTRA-ARTICULAR FRACTURE OF LOWER END OF UNSPECIFIED RADIUS
S52.561A BARTON'S FRACTURE OF RIGHT RADIUS
S52.562A BARTON'S FRACTURE OF LEFT RADIUS
S52.569A BARTON'S FRACTURE OF UNSPECIFIED RADIUS
S52.571A OTHER INTRAARTICULAR FRACTURE OF LOWER END OF RIGHT RADIUS
S52.572A OTHER INTRAARTICULAR FRACTURE OF LOWER END OF LEFT RADIUS
S52.579A OTHER INTRAARTICULAR FRACTURE OF LOWER END OF UNSPECIFIED RADIUS
S52.591A OTHER FRACTURES OF LOWER END OF RIGHT RADIUS
S52.592A OTHER FRACTURES OF LOWER END OF LEFT RADIUS
S52.599A OTHER FRACTURES OF LOWER END OF UNSPECIFIED RADIUS
ICD-9 Code Description ICD-10 CM Codes
729.5 PAIN IN LIMB M79.601 PAIN IN RIGHT ARM
M79.602 PAIN IN LEFT ARM
M79.603 PAIN IN ARM, UNSPECIFIED
M79.604 PAIN IN RIGHT LEG
M79.605 PAIN IN LEFT LEG
M79.606 PAIN IN LEG, UNSPECIFIED
M79.607 PAIN IN UNSPECIFIED LIMB
M79.621 PAIN IN RIGHT UPPER ARM
M79.622 PAIN IN LEFT UPPER ARM
M79.629 PAIN IN UNSPECIFIED UPPER ARM
M79.631 PAIN IN RIGHT FOREARM
M79.632 PAIN IN LEFT FOREARM
M79.639 PAIN IN UNSPECIFIED FOREARM
M79.641 PAIN IN RIGHT HAND
M79.642 PAIN IN LEFT HAND
M79.643 PAIN IN UNSPECIFIED HAND
M79.644 PAIN IN RIGHT FINGERS
M79.645 PAIN IN LEFT FINGERS
M79.646 PAIN IN UNSPECIFIED FINGERS
M79.651 PAIN IN RIGHT THIGH
M79.652 PAIN IN LEFT THIGH
M79.659 PAIN IN UNSPECIFIED THIGH
M79.661 PAIN IN RIGHT LOWER LEG
M79.662 PAIN IN LEFT LOWER LEG
M79.663 PAIN IN UNSPECIFIED LOWER LEG
M79.669 PAIN IN RIGHT LOWER LEG
M79.671 PAIN IN RIGHT FOOT
M79.672 PAIN IN LEFT FOOT
M79.673 PAIN IN UNSPECIFIED FOOT
M79.674 PAIN IN RIGHT TOES
M79.675 PAIN IN LEFT TOES
M79.676 PAIN IN UNSPECIFIED TOES
Yeah! There is a code for that …
ICD-10 Code X38.xxxA
Guess that code?
ICD-10 Code Z72.820
ICD-10 Code W55.42
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Chet Deshmukh, MBA, OTR/L, CPC, CHDA
CEO and Program Director
TherAccess, PLLC
www.theraccess.com
Email: [email protected]
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